Eighteen years of experience in laparoscopic implantation of artificial urinary sphincter in women with intrinsic sphincter deficiency

INTRODUCTION AND OBJECTIVES

Artificial urinary sphincter (AUS) is a treatment option for women with stress urinary incontinence (SUI) after failure of previous surgery or as a primary procedure in severe intrinsic sphincter deficiency (ISD). The aim of the study was to assess the long-term efficacy and risk factors for surgical revision and definitive explantation of AUS laparoscopic implantation in female patients.

METHODS

A retrospective review of all women submitted to AUS implantation between April 2005 and March 2023 was conducted. The AUS was implanted via transperitoneal laparoscopic approach, by two experienced surgeons. The primary endpoint was postoperative continence. Continence was defined as no leakage and no pad usage or leakage and/or pad usage with no impact on social life and failure as leakage and/or pad usage impacting social life. As secondary outcomes, clinical predictive factors for AUS revision and definitive explantation were evaluated.

RESULTS

In the last 18 years, females with a mean age of 68±12 years-old were submitted to laparoscopic implantation of AUS. Early overall complication rate was 16%, but only one case was Clavien-Dindo ≥3. After a median follow-up of 67 months, 22.2% of the patients needed a device revision, the majority due to mechanical device dysfunction. AUS definitive explantation was performed in 16%, mainly due to urethral/vaginal erosion (9.9%) and infection (6.2%). Patients with age ≥70 years and follow-up ≥10 years significantly predisposed for device revision. At the time of the last follow-up, 72% of the patients were keeping the urinary continency.

CONCLUSIONS

Laparoscopic AUS implantation in females is an effective treatment for SUI due to ISD. Meanwhile, adequate patient selection, multidisciplinary evaluation and careful expectation management are essential to achieving good results, concerning their significant complication rate.

Five-year Results from the Prospective, Multicenter, Observational SOUNDS Study of Patients with Overactive Bladder Treated with the InterStim System for Sacral Neuromodulation

BACKGROUND

Although sacral neuromodulation (SNM) for overactive bladder (OAB) is an established therapy, there is a lack of high-quality, long-term data on real-life practice.

OBJECTIVE

To report on real-life therapeutic effectiveness, quality of life (QoL), disease severity, and safety as well as patient-reported symptom bother after approximately 5 yr of follow-up.

DESIGN, SETTING, AND PARTICIPANTS

A total of 291 OAB patients were enrolled at 25 French sites according to local standard of care. Sacral neuromOdUlation with InterStim therapy for intractable lower uriNary tract DySfunctions (SOUNDS) enrolled both de novo and replacement patients, and a total of 229 patients were permanently implanted.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Over the course of the study, patients were followed up six times with two follow-ups in the year after implantation and annually thereafter. Of the patients, 154 completed the final follow-up after a mean of 57.7 ± 3.9 mo.

RESULTS AND LIMITATIONS

The mean number of daily leaks in urinary urge incontinence (UI) patients was reduced from 4.4 ± 3.3 at baseline to 1.8 ± 2.6 after 5 yr in de novo and from 5.4 ± 4.9 to 2.2 ± 3.0 in replacement patients (both p < 0.001). Likewise, the number of voids in urinary frequency patients was reduced compared with baseline (de novo: reduced from 12.6 ± 4.0 [baseline] to 9.6 ± 4.3 [5 yr]; replacements: reduced from 11.5 ± 4.3 [baseline] to 9.2 ± 3.1 [5 yr]; both p < 0.05). Complete continence rates after 5 yr were 44% (25/57) in de novo and 33% (5/15) in replacement UI patients, and 68% (39/57) and 67% (10/15) of UI patients were categorized as therapy responders by showing a >50% improvement in leaks. Disease severity (Urinary Symptom Profile domain 2), Numeric Rating Scale-based symptom bother, and disease-specific QoL (Ditrovie) improved significantly in both groups at all visits (p < 0.001). Adverse events related to device or procedure occurred in 51% (140/274) of patients, with 66% (152/229) of the events being classified as minor (Clavien-Dindo grade I and II). Surgical revisions were reported in 39% (89/229), which include permanent explants in 15% (34/229) of patients.

CONCLUSIONS

SOUNDS demonstrates the sustained effectiveness and QoL improvements of SNM in OAB patients after 5 yr in real-world conditions while maintaining an acceptable safety profile consistent with literature.

PATIENT SUMMARY

This study confirmed that French overactive bladder patients had a sustained symptom and bother reduction, and improvements in quality of life up to 5 yr after sacral neuromodulation device implantation.

Sacral Neuromodulation with the InterStim System for Overactive Bladder: 3-Year Results from the French Prospective, Multicenter, Observational SOUNDS Study

BACKGROUND

SOUNDS strengthens the evidence basis of sacral neuromodulation (SNM) for overactive bladder (OAB) through real-world data.

OBJECTIVE

To analyze diary-based effectiveness, quality of life (QoL), disease severity, symptom bother, and safety data for SNM with the InterStim system up to 3 yr after implantation.

DESIGN, SETTING, AND PARTICIPANTS

Twenty-five representative French sites enrolled 291 patients with OAB followed according to the local standard of care. Overall, 229 patients received a de novo or replacement InterStim implant and had four follow-up visits, two within the first yr and annually thereafter. A total of 190 patients completed the fourth follow-up visit after a mean of 33.7 ± 3.7 mo.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The effectiveness outcomes measured were changes in daily voids and leaks and the therapy responder rates. Other outcomes included validated QoL data (Ditrovie and EuroQol 5-dimension 5-level questionnaires), disease severity (Urinary Symptom Profile [USP]), symptom bother rated using a numeric rating scale (NRS), and safety data. Follow-up data were compared to baseline results using the Wilcoxon signed-rank test.

RESULTS AND LIMITATIONS

Average daily voids and leaks were significantly reduced at all time points up to 3 yr after implantation (p < 0.05) except for voids at 21 mo in the group receiving a replacement device. The therapeutic response for urinary urge incontinence at the fourth follow-up was 72% for the de novo group and 86% for the replacement group. Disease-specific QoL (Ditrovie), OAB-specific symptom severity (USP domain 2), and NRS-rated disease bother were significantly improved at all visits (p < 0.001). Device- or procedure-related adverse events occurred in 49% of patients, with 68% of the events classified as minor (Clavien-Dindo grade I or II). Surgical revisions were performed in 33% of patients, including permanent removal in 13%, over a mean exposure time of 44.4 ± 15.3 mo.

CONCLUSIONS

This study confirms the safety and effectiveness of SNM for OAB and improvements in QoL and disease bother in real life.

PATIENT SUMMARY

Our study in French patients with overactive bladder showed that disease symptoms and bother were significantly reduced and quality of life was significantly improved over a study duration of approximately 3 yr after implantation of a device to stimulate nerves that control the bladder. This trial is registered at ClinicalTrials.gov as NCT02186041.

Prolapsus et colpocèle antérieure. Double promontofixation cœlioscopique. Technique

Genito-urinary prolapse is a common disease that requires a global approach which includes all the compartments. Sacrocolpopexy with anterior and posterior mesh allows long-lasting anatomical restoration with a preservation of the sexual function. The laparoscopic approach is a modern and efficient answer for this functional surgery.

[Paraneoplastic urticarial vasculitis and renal carcinoma]

Paraneoplastic syndromes have been described in various types of tumours, but are rarely associated with renal cancer. Paraneoplastic cutaneous manifestations, consisting of urticarial vasculitis are exceptional and can sometimes constitute the presenting sign of a completely asymptomatic renal cancer. This vasculitis resolves after curative treatment of the tumour, confirming its paraneoplastic nature. The authors report a case of a paraneoplastic urticarial vasculitis associated with the discovery of an asymptomatic renal carcinoma in a 37-year-old man and discuss paraneoplastic cutaneous syndromes that must be recognised to allow earlier diagnosis of renal tumours.

[Pelvic pain caused by bladder leiomyoma: diagnostic and radiologic difficulties]

Uterine leiomyoma is a frequent benign lesion. It is usually asymptomatic and can be responsible for acquired dysmenorrhoea in some women, leading to gynaecological assessment. However, the development of this type of muscle lesions arising from the bladder wall and accompanied exclusively by dysmenorrhoea is rare. It is very difficult to study the anatomical relations of the lesion and distinguish it from other pelvic, genital or urinary tract tumours. The authors discuss the diagnostic aspects and therapeutic management in the light of a case of bladder leiomyoma in a 39-year-old woman.

[Ureteral multiplicity: report of 3 cases]

The ureteric multiplicity is a rare malformation with about one hundred cases described in the literature. The rarity of this anomaly and the complexity of possible associated anomalies often make the preoperative diagnosis difficult. The authors report 1 case of partial quadruplicate ureter associated with bladder duplication and 2 cases of triplicate ureter, corresponding to types I, II and III of Smith's classification. Based on their experience and a review of the literature, they discuss the diagnostic approach and treatment of these anomalies.

[Pharmacologic stimulation of ejaculation with midodrine hydrochloride (Gutron) for medically assisted reproduction in spinal injury]

INTRODUCTION

Midodrine hydrochloride (Gutron) is proposed to induce ejaculation in spinal injury patients desiring paternity as an alternative to vibromassage, electrostimulated ejaculation and surgical collection of spermatozoa. The authors report their experience in 10 spinal injury patients.

PATIENTS AND METHODS

14 trials of pharmacologically-induced ejaculation were performed in a context of medically assisted reproduction (MAR) in 10 spinal injury patients (7 with paraplegia > T11; 1 with paraplegia < or = T11; 2 with quadriplegia) an average of 4.5 years after the injury. Patients had a mean age of 28.5 years (range: 18 to 36 years). Nine had persistent reflex erections. After IC injection of prostglandin E, 10 to 30 mg of Gutron was administered by slow i.v. infusion. Spermatozoa were collected during antegrade ejaculation and/or in previously alkalinised urine.

RESULT

Ejaculation was obtained in 10 cases (71.4%), either antegrade (7 cases), or retrograde (3 cases). The 4 failures corresponded to ejaculation failure in 3 cases and adverse effects of Gutron (hypertension) in 1 case. However, storage of spermatozoa could be performed in only 4 cases (40%), as pyospermia or severe necrospermia were observed in 6 cases.

CONCLUSIONS

Midodrine hydrochloride gives good results in terms of ejaculation in spinal injury patients. However, the quality of semen collected is often poor due to the long interval since the initial trauma. Midodrine hydrochloride, ideally used after antibiotic treatment, can nevertheless constitute an alternative to other techniques.